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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602388
Report Date: 11/19/2024
Date Signed: 11/19/2024 09:58:16 AM

Document Has Been Signed on 11/19/2024 09:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EASTER SEALS SOUTHERN CALIFORNIA MOUNTAIN VIEWFACILITY NUMBER:
198602388
ADMINISTRATOR/
DIRECTOR:		ANDRES ROJASFACILITY TYPE:
735
ADDRESS:3799 MOUNTAIN VIEW AVETELEPHONE:
(818) 512-2494
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 4CENSUS: 4DATE:
11/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:33 AM
MET WITH:Massoumeh Ho - LVNTIME VISIT/
INSPECTION COMPLETED:
10:05 AM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit to follow up on an incident report submitted to the department on 11/4/24. LPA met with Massoumeh Ho and explained the reason for the visit. Administrator arrived 20 minutes later.

On 11/4/24 facility submitted an incident report to report staff #1(S1) had behaved inappropriate with client #1(C1). Per the report on 11/2/24 administrator received communication that S1 yelled and cursed at C1 at around 11pm. On 11/18/24 LPA Flores contacted administrator over the phone, per administrator, it was reported that S1 used foul language and yelled at C1 when S1 was trying to speak to S1. S1 was suspended and an internal investigation is being conducted. LPA reviewed S1's employment documents. Facility provided initial training on 10/10/24 and 10/16/24 which includes zero tolerance, client's personal rights, and abuse.

Due to the incident taken place, in which S1 behaved verbally inappropriate with the client, a deficiency has been noted today per Title 22 Regulations.

Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/19/2024 09:58 AM - It Cannot Be Edited


Created By: Mary G Flores On 11/19/2024 at 09:04 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA MOUNTAIN VIEW
FACILITY NUMBER: 198602388

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/03/2024
Section Cited
CCR
80072(a)(1)

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80072 Personal Rights: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1)To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement is not met as evidence by:
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 Administrator will provide an update on decision on internal investigation, documents pertaining the decision such as a termination letter or warning and training provided to S2 by 12/3/24.
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Based on documents reviewed licensee did not ensure S1 did not yelled and or used foul language with C1 which poses an immediate risk to the health, safety, or personal rights of the clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024


LIC809 (FAS) - (06/04)
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